An intensivist on a learning frenzy. Caring for the critically ill using evidence-based medicine.
This is a question I remember asking myself quite a bit during my training when I used to check/trend lactate levels more than I do today. Does it really matter whether I check it from an arterial line or from a venous stick? This study which was a prospective study of 100 patients who had …
Continue reading Lactate Measurements: Venous or Arterial Samples?
There's a pendulum in medicine. Some things are over recognized and aggressively treated, some things are under appreciated (like subtle decreases in serum bicarb showing that the patient is becoming more acidotic and no one notices because the patient has obesity hypoventilation syndrome and their baseline bicarb is 34 and now has a bicarb of …
Continue reading Lactic Acid has a WIDE Differential Diagnosis (not just Sepsis)
I need to eat my words on this one, because now there's data to show that there's a benefit to rechecking lactate levels in septic patients, but not for the reasons why one would think. During my rounds over the course of the weekend, I recall telling several nurses that there's no data to suggest …
Continue reading Lactic Acid is an Alarm, not a Treatment in Sepsis and Septic Shock
Ultrasound assessment of the inferior vena cava for fluid responsiveness: easy, fun, but unlikely to be helpful This is where I stand on the matter today, November 3rd, 2020. I am open to changing my mind with new data. Guiding fluid responsiveness, as I’ve covered here, is a huge pain in the butt. But giving …
Continue reading Inferior Vena Cava (IVC) POCUS for Resuscitation
These are the 2019 European Society of Cardiology and European Respiratory Society Guidelines for the Diagnosis and Management of Acute Pulmonary Embolism. I must say, these are my favorite guidelines for PE and they came out just a few weeks ago on August 31st. It seems as if PE is just on every differential, as …
Is your shop still using strict NPO after midnight for its surgical patients? It’s time to talk to the powers that be to have this changed, supported by evidence, of course. The controversy of “Strict NPO After Midnight” has been ongoing for many years now as the data has suggested it’s silly but still performed. …
Continue reading NPO after Midnight: What do the Guidelines Say?
Every possible option to decreased morbidity, mortality, and costs are worth looking at in my book. The study that I am reviewing at this moment was published in 2017. I am ashamed that I had not run into it until today (10/19/19). It's challenging to stay up to date in everything. I digress. It is …
Continue reading Thiamine and Renal Failure in Septic Shock Patients
I have great disdain for delirium. Natural light brings me great joy. Today, for example, the sun isn't shining bright. The day is cloudy and gloomy. I am, in turn, a little grouchy. Daylight savings is coming and I'm already upset about it. I can turn on the light but it won't be the same. …
Continue reading Delirium in Mechanically Ventilated Patients: Let the Natural Light in!
I am not a trauma surgeon. I am not a trauma physician. I do not take care of trauma patients in my current practice. I did several rotations in the trauma intensive care unit during my fellowship training but by know means am I going to pretend to have the knowledge that my colleagues who …
Continue reading Resuscitation of Trauma Patients: 0.9% NaCl (saline) or Plasma-lyte?
This was a post-hoc analysis of the FLORALI trial that I have reviewed before on this medium. In that study they compared patients who had hypoxemic respiratory failure by putting them on 1:1:1 on high flow nasal cannula (HFNC), standard oxygen therapy, and non-invasive ventilation (NIV aka BiPAP). They found that BiPAP was not beneficial …
Continue reading BiPAP should not be used in Immunocompromised patients